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NASPGHAN issues updated clinical guidelines for children with NAFLD
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The North American Society for Pediatric Gastroenterology, Hepatology and Nutrition and Expert Committee on NAFLD have updated its clinical practice guidelines to reflect new recommendations on the screening, diagnosis and management of nonalcoholic fatty liver disease among children.
“The emergence of NAFLD has been an important change in the landscape of pediatric liver disease. However, substantial gaps in knowledge remain and are research priorities,” Miriam B. Vos, MD, MSPH, FAHA, of Emory University School of Medicine, and Children’s Healthcare of Atlanta, and colleagues wrote.
Vos and other specialists in pediatrics, hepatology, gastroenterology, nutrition, cardiology, endocrinology and pediatric obesity management developed recommendations based on a comprehensive research review for management of pediatric NAFLD, including:
Screening
- All children with obesity or overweight with additional risk factors aged between 9 and 11 years should be considered for screening of NAFLD.
- Younger children may be screened if risk factors exist in the family, such as severe obesity, NAFLD/nonalcoholic steatohepatitis or hypopituitarism. Siblings and parents of children with NAFLD should be screened if risk factors persist.
- The best screening technique for NAFLD is measuring alanine aminotransferase; interpretation of ALT should be based on sex-specific upper limits of normal in children and not individual laboratory limits, per the researchers.
- Routine ultrasound is not recommended as a screening test for children.
- Follow-up screening for NAFLD is recommended every 2 to 3 years if the initial screening test is normal and if risk factors for NAFLD remain unchanged.
Diagnosis and assessment
- If a clinician is evaluating a child with suspected NAFLD, it is recommended to exclude any alternative etiologies for elevated ALT or hepatic steatosis and investigate the presence of any co-existent chronic liver diseases.
- Liver biopsy should be considered for assessing NAFLD only in children who have increased risk for NASH or advanced fibrosis.
- Ultrasound and CT are not recommended for measuring or quantifying steatosis.
Treatment options
- Lifestyle modifications, such as improved diet and increased physical activity, are the first-line treatments recommended for all children with NAFLD.
- Avoid sugar-sweetened drinks to decrease adiposity
- Increase physical activity and limit screen time activities to less than 2 hours per day.
- There are currently no available medications or supplements the society recommends to treat NAFLD.
- Bariatric surgery is not recommended as a treatment option for children with NAFLD, due to lack of clinical outcome data. Bariatric surgery may be an option for adolescents who have serious comorbidities.
Long-term care of children with NAFLD
- Clinicians should follow children with NAFLD on a yearly basis to monitor any progression of the disease and provide treatment.
- A repeat liver biopsy to determine any progression of disease and to guide treatment may be considered 2 to 3 years after first liver biopsy, if new or ongoing risk factors persist/arise.
- Blood pressure should be monitored in children with NAFLD, for risk of any cardiovascular event.
- Children should be screened for dyslipidemia at diagnosis and periodically, as well as for diabetes using a fasting serum glucose level or a glycosylated hemoglobin level.
The researchers note that adolescence is a time where children may choose to engage in high-risk behaviors that may affect healthy habits. Although recent data suggested light to moderate drinking may have a “favorable effect on NAFLD”, underage consumption of alcohol is not recommended. The researchers do recommend standard counseling for adolescents and that health care providers also counsel to teach them about the potential effects of increased fibrosis progression with binge drinking. In addition, families of children with NAFLD should be counseled for risk for second hand smoke exposure and adolescents with NAFLD should be counseled against any type of smoking or nicotine inhalant.
The researchers further state that there are many gaps in knowledge on NAFLD and pediatric liver disease, including cost-effective strategies for screening, diagnosis and long-term follow-up, well-designed clinical trials to identify novel medications and the role of weight loss surgery, identifying risk factors in childhood to predict progression vs. regression, among others.
Disclosures: Vos reports receiving research funding from Resonance Health Inc., serves on a DSMB for Aegerion and is a consultant for Immuron, Intercept Pharmaceuticals, Shire and Target Pharmasolutions. Please see the full study for a list of all other researchers’ relevant financial disclosures.
Perspective
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Megan Butler, MD
The guidelines reinforce what most of us are already doing in clinical practice. They are helpful because the researchers went a step further to recommend routine screening in certain populations. Obviously when children have elevated liver enzymes, they will come see us in hepatology, but I think it’s helpful from a primary care standpoint, who are seeing these kids at routine care checks. For that, these guidelines are helpful.
In the long-term we will find screening obese children aged between 9 and 11 years will be beneficial. One downside is that we don’t have a lot of information as far as the incidence and natural history of the illness. It seems the children who are diagnosed when younger seem to have a more aggressive phenotype, so finding these children and diagnosing them sooner rather than later will be helpful in the long-run.
Lifestyle modifications for treating and preventing nonalcoholic fatty liver disease are the only factors that have been consistently proven to improve liver histology in pediatric fatty liver disease. Certain studies have yielded some excitement as far as medications or supplements, but when you look at the data again or do a meta-analysis, it does not improve liver long-term. So, we have to go back to step one: diet, exercise, physical activity, limiting sweetened beverages. It is the mainstay of our treatment at this point. There is certainly a lot of research happening to identify other avenues we can go to, but we don’t have those answers yet.
I hope that with more research and understanding we will have more set guidelines as far as other populations to screen. The guidelines presented here specifically targeted 9- to 11-year-olds who were obese or had other comorbid issues such as diabetes, sleep apnea and family history. It mentions screening younger kids if there is a family history, but I think over time we will see more definitive guidelines as far as who to screen in the younger kids. But what about the older kids? The AAP released guidelines in 2007 recommending biannual screening starting at age 10 years for obese populations. The NASPGHAN guidelines did not quite go to that step, but there is still this question mark if you screen them once then how long until you screen again? These are the questions we still don’t have answers for yet.
I’m glad these guidelines came out because they go a long way as far as cementing what most hepatologists have been doing and expanding in some ways with the recommendations for screening in obese populations. We still have a long way to go to understanding this disease and understanding how to best manage and diagnose it.
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